Guidelines for using the symptom listings

The protocol next provides Guidelines for the application of the symptom listings to the patient. For instance: "The widely distributed symptoms are connected as a coherent entity through the temporal and causal relationships revealed in the history. If this coherence of symptoms is absent, the diagnosis is in doubt."

The Case Definition then includes a detailed discussion section on each of the symptom groupings and its major features. It includes a short section on features of ME/CFS in children.

Clinical Evaluation and Laboratory Testing

The next major section describes the steps in the clinical evaluation of ME/CFS (that is, how the physician proceeds to assess the patient's illness):

"Assess the total illness burden, taking a thorough history, physical examination and investigations as indicated to confirm clinical findings and to rule out other active illness processes. The patient evaluation is to be used in conjunction with the clinical definition." 

The section presents a detailed protocol for the patient history and physical examination.

Finally the definition lists the Laboratory and Investigative Protocol. First is a listing of routine lab tests for general diagnostic purposes. These tests are normally given to test for infections, various deficiencies, abnormal pathophysiological processes, organ function, autoimmune disease, etc. Abnormalities could indicate exclusionary conditions.

ME/CFS often shows near normal routine lab tests; although some tests may be somewhat abnormal and thereby be a sign of ME/CFS.

The protocol then lists further specialized laboratory and other testing. This testing falls into two categories:

(a) specialized testing for other exclusionary conditions

(b) testing for further exploration of specific ME/CFS symptom complexes and pathophysiology. This testing can also be used to identify co-morbid conditions.

Specialized tests are indicated when the routine lab tests, or history/examination, indicate that testing be undertaken for other exclusionary conditions such as: infectious diseases (HIV, hepatitis, western blot for Lyme disease, parasites, TB, etc.); neurological disease (MRI for MS and cervical stenosis); specific endocrine testing; autoimmune testing; sleep studies for sleep apnea and other possible exclusionary conditions.

Specialized testing may also be done for the further exploration of ME/CFS symptom complexes and pathophysiology; and also for co-morbid conditions. The tests may be indicated by the seriousness of the symptom-complex or for possible treatment. Such tests could include: immune testing (when available); brain scans; tilt table testing for orthostatic symptoms; sleep studies for ME/CFS sleep pathology; 24-hour Holter monitoring for cardiac symptoms; and neuropsychological testing for cognitive dysfunction.

Finally, the protocol discusses in some detail the differential diagnoses between ME/CFS and fibromyalgia; and ME/CFS and psychiatric disorders.

As there are, at the present time, no clear, readily available true diagnostic markers for the illness (which would constitute a diagnostic "gold standard"), we consider the Canadian Criteria to be a "silver standard" for ME/CFS diagnosis and currently provide the most accurate diagnostic tool for ME/CFS.